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f v _ -APPLICATION FOR PE"M 7 - t SAN JOAQUIN LOCA! HEALTH DISTRICT 1601 E. HAZELTON A'VE., STOCKTON,. CA PERMIT NO. ;u. Tel ephore (209) 466-6781 Y ERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED �� (Complete in Triplicate) f 4 A �lcati-!n�is-here`b made to the San Joa uin LocaHealth District for a r install the work herein PPY q permit-to construct'ard,a described. This application is made in compliance with San Joaquin County ordinance No. 549 for sewage or No. 1862 for well/pump -�-/and the Rules and Regulations of the -San Joaquin Local'Health District, Y � lob Address_' ?.7r:33 -, � Subdivision Name Owner's Name l" YR�,�' Address Phone Contractor's Name h•Z Z License No. r3 t 3 Phone TYPE OF WELL/PUMP WORK: NELi WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP, INSTALLATION %Y`1 SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL'. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation 'IL �'Oomestic/Private 'Gravel Pack ❑ Tracy Dia. of Well Casing y- - ❑ Public C1 Other ❑ Delta Type of Casing n.t L ` 711 rrigation -7 'Vo Approx. ❑ Eastern Depth Specifications ❑ Cathodic ProtectionDepth of Grout Seal ' �} s ❑Geophysical Other Type of Grout �' c 0 s Surface Seal Installed by , Repair Work Done ❑ Type of.._Pump - r� "5H.P. /— State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 60') Depth Filler Material '(Below 50') TYPE OF SEPTIC WORK: N£W..INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ^� available within 200 feet.) V.1 Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments \4 PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No." & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ v � I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. . Home owner or 1icersed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawing on reverse side, w t/ A111;.G+�7L Title: / 4 -- Date: Signed X IFO D PARTMENT USE ONL Application Accepted by Area _ ❑ Stk 466-6781 �r Additional Comments: L Lodi 369-3621 Pit orGrou Inspection by � Date A_i,Z0y ❑ Manteca 823-7104 - I Final Inspection by I Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. .. , INFO 04_i��/Y 378 ` MD f —�c� —?14 ti EH 13-24 REV. 10/82 ;� 10/82 500 14-26